3
New policies introduced at different government levels National government –Responsibility of local governments –Specific issues (focus on access, quality and equity) –Legislation or agreements + budget infusion Local government –Experimentation with choice of providers, purchaser- provider split, contracting, privatisation, hospitals mergers and closure, new primary care models, integrated care and more

4
Impact of new policies Impact of local-government reforms and national agreements limited compared to new legislation The formation of reforms can often be explained by a political logic (i.e. maintaining legitimacy) –Politicians produce rhetoric, plans and actual changes –Coherence not necessary for survival Changes in welfare and advances in medical technology more important than both local and national government reform

11
How would you assess health care services today compared to 10 years ago? Better than 10 years ago15,6% About the same as 10 years ago17,6% Worse than 10 years ago42,3% Don´t know/uncertain24,5% Total100% Source: Rosén P. Population survey in county council of Östergötland (Sample = 4 000 with 58% response rate, n = 2284, ages 18+).

12
Why? Cost-containment policies in mid 90s and increased pressure for explicit priority setting Political rhetoric –Election every fourth year; shift of local government common. Opposition (and media) has an interest to highlight problems. Increased transparency related to access and quality (absolute level and differences) Demand for patient influence and less reliance on experts

13
Waiting times and government policies Important problem for politicians since late 1980s –Used as an argument for overall reform (privatisation) –Waiting time guarantees, budget infusion from national level Several explanations behind existing waiting times –Wider indications for treatment most important –Waiting list for cataract surgery doubled 1990-2000; the volume produced increased by 140%

14
Number of hip replacements in Sweden per 100 000 population and age group 1994, 1999 and 2004 Source: Sjukvårdsdata i Fokus, SKL, 2006

15
Number of coronary bypass and PCI in Sweden per 100 000 population and age 1994, 1999 and 2004 Coronary bypassPCI Source: Sjukvårdsdata i Fokus, SKL, 2006

17
Variation in access to cancer therapy Local priorities not transparent and limited by budget criteria Less acceptance by national government (and the population) of variation in access to treatment (post-code rationing) Towards a national cancer-plan (= agreement + budget infusion)? –increased use of national guidelines, less discretion for decision-making at local level and additional funding?

19
Some challenges for the future Balance between national and local decision- making –Ongoing parliamentary committee expected to suggest larger regions to replace county councils Long-run financing of services (from 2015) –Alternatives to tax funding? Recruitment of human resources –Both municipalities and county councils Development of primary care and integration of services